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Bacanlı A, Unsel-Bolat G, Suren S, Yazıcı KU, Callı C, Aygunes Jafari D, Kosova B, Rohde LA, Ercan ES. Effects of the dopamine transporter gene on neuroimaging findings in different attention deficit hyperactivity disorder presentations. Brain Imaging Behav 2021; 15:1103-1114. [PMID: 33469789 DOI: 10.1007/s11682-020-00437-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2020] [Indexed: 11/29/2022]
Abstract
Attention-Deficit/Hyperactivity Disorder (ADHD) is a phenotipically and neurobiologically heterogeneous disorder. Deficiencies at different levels in response inhibition, differences in dopamine transporter genotype (DAT1) and various symptomatic presentations contribute to ADHD heterogeneity. Integrating these three aspects into a functional neuroimaging research could help unreval specific neurobiological components of more phenotipically homogeneous groups of patients with ADHD. During the Go-NoGo trial, we investigated the effect of the DAT1 gene using 3 T MRI in 72 ADHD cases and 24 (TD) controls that typically developed between the ages 8 and 15 years. In the total ADHD group, DAT1 predicted homozygosity for the 10R allele and hypoactivation in the anterior cingulate cortex and paracingulate cortex. There were no significant activation differences between DAT1 10R/10R homozygotes and 9R carriers in TD controls. Subjects with predominantly inattentive ADHD (ADHD-I) presentation with DAT1 10R/10R homozygous reduced neuronal activation during Go trial particularly in the frontal regions and insular cortex, and in the parietal regions during NoGo trial (brain regions reported as part of Default Mode Network- DMN). Additionally, DAT1 10R/10R homozygousness was associated with increased occipital zone activation during only the Go trial in the ADHD combined presentation (ADHD-C) group. Our results point the three main findings: 1) The DAT1 gene is 10R homozygous for differentiated brain activation in ADHD cases but not in the TD controls, supporting the DAT1 gene as a potential marker for ADHD, 2) The relationship between the DAT1 gene and the occipital regions in ADHD-C group which may reflect compensatory mechanisms, 3) The relationship between DAT1 gene and the reduced DMN suppression for 9R carriers probabaly stems from the ADHD-I group.
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Affiliation(s)
- Ali Bacanlı
- Department of Child and Adolescent Psychiatry, Zubeyde Hanim Training and Research Hospital, Başkent University, Izmir, Turkey
| | - Gul Unsel-Bolat
- Department of Child and Adolescent Psychiatry, Balıkesir University, Balıkesir, Turkey.
| | - Serkan Suren
- Department of Child and Adolescent Psychiatry, Medical Park Hospital, Samsun, Turkey
| | - Kemal Utku Yazıcı
- Department of Child and Adolescent Psychiatry, Faculty of Medicine, Fırat University, Elazığ, Turkey
| | - Cem Callı
- Department of Radiology, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Duygu Aygunes Jafari
- Department of Medical Biology, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Buket Kosova
- Department of Medical Biology, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Luis Augusto Rohde
- ADHD Outpatient Program, Department of Psychiatry, Hospital de Clinicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, Brazil.,National Institute of Developmental Psychiatry for Children and Adolescents, São Paulo, Brazil
| | - Eyup Sabri Ercan
- Department of Child and Adolescent Psychiatry, Faculty of Medicine, Ege University, Izmir, Turkey
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Cao Y, Lin X, Chen L, Ji L, Zhang W. The Catechol-O-Methyltransferase and Dopamine Transporter Genes Moderated the Impact of Peer Relationships on Adolescent Depressive Symptoms: A Gene-Gene-Environment Study. J Youth Adolesc 2018; 47:2468-2480. [PMID: 30242586 DOI: 10.1007/s10964-018-0925-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 09/01/2018] [Indexed: 01/28/2023]
Abstract
Behavioral genetics studies and new empirical evidence suggest that depression cannot simply be explained by the influence of single genes but that gene-gene-environment interactions are important to better understanding the etiology of depression. The present study investigated the main and interactive effects of COMT gene Val158Met polymorphism, DAT1 gene rs27072 polymorphism, and peer relationships (i.e., peer acceptance and rejection) on adolescent depressive symptoms. In a sample of 1045 Chinese Han adolescents (Mage = 12.34 ± 0.47 years, 50.1% girls), saliva samples, self-reported depressive symptoms and within-classroom peer nominations were collected. After controlling for gender, age, and SES, the three-way interaction of COMT, DAT1, and peer acceptance significantly concurrently predicted adolescent depressive symptoms. Adolescents with ValVal genotype of COMT and CC genotype of DAT1 were more sensitive to acceptance, compared to their counterparts carrying other combined genotypes. However, a similar three-way interaction was not significant in the case of peer rejection. Additionally, the split-half validation generally replicated these findings. More importantly, this study underscores complex polygenic underpinnings of depression and lends support for the gene-gene-environment interactions implicated in the etiology of depressive symptoms.
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Affiliation(s)
- Yanmiao Cao
- Department of psychology, Shandong Normal University, Jinan, China
| | - Xiaonan Lin
- Department of psychology, Shandong Normal University, Jinan, China
| | - Liang Chen
- Department of psychology, Shandong Normal University, Jinan, China
| | - Linqin Ji
- Department of psychology, Shandong Normal University, Jinan, China
| | - Wenxin Zhang
- Department of psychology, Shandong Normal University, Jinan, China.
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Akay AP, Kaya GÇ, Kose S, Yazıcıoğlu ÇE, Erkuran HÖ, Güney SA, Oğuz K, Keskin D, Baykara B, Emiroğlu Nİ, Eren MŞ, Kızıldağ S, Ertay T, Özsoylu D, Miral S, Durak H, Gönül AS, Rohde LA. Genetic imaging study with [Tc- 99m] TRODAT-1 SPECT in adolescents with ADHD using OROS-methylphenidate. Prog Neuropsychopharmacol Biol Psychiatry 2018; 86:294-300. [PMID: 29684537 DOI: 10.1016/j.pnpbp.2018.04.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 04/11/2018] [Accepted: 04/18/2018] [Indexed: 01/13/2023]
Abstract
AIM To examine theeffects on the brain of 2-month treatment withamethylphenidate extended-release formulation (OROS-MPH) using [Tc-99m] TRODAT-1SPECT in a sample of treatment-naïve adolescents with Attention Deficit/Hyperactivity Disorder (ADHD). In addition, to assess whether risk alleles (homozygosity for 10-repeat allele at the DAT1 gene were associated with alterations in striatal DAT availability. METHODS Twenty adolescents with ADHD underwent brain single-photon emission computed tomography (SPECT) scans with [Tc-99m] TRODAT-1 at baseline and two months after starting OROS-MPH treatment with dosages up to 1 mg/kg/day. Severity of illness was estimated using the Clinical Global Impression Scale (CGI-S) and DuPaul ADHD Rating Scale-Clinician version (ARS) before treatment,1 month and 2 months after initiating OROS-MPH treatment. RESULTS Decreased DAT availability was found in both the right caudate (pretreatment DAT binding: 224.76 ± 33.77, post-treatment DAT binding: 208.86 ± 28.75, p = 0.02) and right putamen (pre-treatment DAT binding: 314.41 ± 55.24, post-treatment DAT binding: 285.66 ± 39.20, p = 0.05) in adolescents with ADHD receiving OROS-MPH treatment. Adolescents with ADHD who showed a robust response to OROS-MPH (n = 7) had significantly greater reduction of DAT density in the right putamen than adolescents who showed less robust response to OROS-MPH (n = 13) (p = 0.02). However, between-group differences by treatment responses were not related with DAT density in the right caudate. Risk alleles (homozygosity for the 10-repeat allele of DAT1 gene) in the DAT1 gene were not associated with alterations in striatal DAT availability. CONCLUSION Two months of OROS-MPH treatment decreased DAT availability in both the right caudate and putamen. Adolescents with ADHD who showed a robust response to OROS-MPH had greater reduction of DAT density in the right putamen. However,our findings did not support an association between homozygosity for a 10-repeat allele in the DAT1 gene and DAT density, assessedusing[Tc-99m] TRODAT-1SPECT.
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Affiliation(s)
- Aynur Pekcanlar Akay
- Deparment of Child and Adolescent Psychiatry, Dokuz Eylul University, Izmir, Turkey.
| | - Gamze Çapa Kaya
- Deparment of Nuclear Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Samet Kose
- Department of Psychology, H. Kalyoncu University, Gaziantep, Turkey; Medical School of Houston, Center for Neurobehavioral Research on Addictions, University of Texas, Houston, TX, USA
| | | | - Handan Özek Erkuran
- Dr.Behçet Uz Pediatrics, Pediatric Surgery Research andTraining Hospital, Deparment of Child and Adolescent Psychiatry, Izmir, Turkey.
| | - Sevay Alşen Güney
- Deparment of Child and Adolescent Psychiatry, Dokuz Eylul University, Izmir, Turkey
| | - Kaya Oğuz
- Department of Computer Engineering, Izmir University of Economics, Izmir, Turkey
| | - Duygu Keskin
- Deparment of Psychiatry, EgianUniversity, Izmir, Turkey
| | - Burak Baykara
- Deparment of Child and Adolescent Psychiatry, Dokuz Eylul University, Izmir, Turkey
| | | | - Mine Şencan Eren
- Deparment of Nuclear Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Sefa Kızıldağ
- Deparment of Molecular Biology and Genetics, Dokuz Eylul University, Izmir,Turkey
| | - Türkan Ertay
- Deparment of Nuclear Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Dua Özsoylu
- Deparment of Molecular Biology and Genetics, Dokuz Eylul University, Izmir,Turkey
| | - Süha Miral
- Deparment of Child and Adolescent Psychiatry, Dokuz Eylul University, Izmir, Turkey
| | - Hatice Durak
- Deparment of Nuclear Medicine, Dokuz Eylul University, Izmir, Turkey
| | | | - Luis Augusto Rohde
- Department of Psychiatry, Federal University of Rio Grande do Sul, Brazil; ADHD Program, Hospital de Clínicas de Porto Alegre, Brazil
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Stolf AR, Müller D, Schuch JB, Akutagava-Martins GC, Guimaraes LSP, Szobot CM, Halpern R, Kessler FHP, Pechansky F, Roman T. Association between the Intron 8 VNTR Polymorphism of the DAT1 Gene and Crack Cocaine Addiction. Neuropsychobiology 2018; 75:141-144. [PMID: 29332099 DOI: 10.1159/000485128] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 11/08/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND This study aims to compare allele and genotype frequencies of a 30-bp variable number of tandem repeats (VNTR) polymorphism of the DAT1 gene, located at intron 8, between adult crack cocaine users and nonaddicted individuals. Due to its involvement in drug addiction, this gene is a good candidate for molecular studies. METHODS A cross-sectional sample of 239 current adult crack abusers or dependents from in- and outpatient clinics and 211 control individuals was collected in Brazil. They were evaluated using ASRS, ASI-6, WAIS-III, and MINI assessments. DNA samples extracted from whole blood were genotyped for the intron 8 VNTR in DAT1. RESULTS Logistic regression analysis was performed and controlled for gender, age, ethnicity, educational level, and comorbidities of clinical interest (generalized anxiety disorder, suicide risk, major depressive episode, and attention deficit/hyperactivity disorder). This analysis showed that the 6R6R genotype was associated with crack cocaine addiction (OR = 1.844; CI = 1.101-3.089; p = 0.020). CONCLUSIONS Our results are consistent with the role of DAT1 in the neurobiology of drug addiction. Nevertheless, the study of other genes, environmental factors, and their interactions is also important to gain a broader understanding of this condition.
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Affiliation(s)
- Anderson R Stolf
- Center for Drug and Alcohol Research (CPAD), Hospital de Clínicas de Porto Alegre (HCPA), Unidade Álvaro Alvim, Porto Alegre, Brazil
| | - Diana Müller
- Department of Genetics, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Jaqueline B Schuch
- Center for Drug and Alcohol Research (CPAD), Hospital de Clínicas de Porto Alegre (HCPA), Unidade Álvaro Alvim, Porto Alegre, Brazil.,Department of Genetics, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | | | - Luciano S P Guimaraes
- Center for Drug and Alcohol Research (CPAD), Hospital de Clínicas de Porto Alegre (HCPA), Unidade Álvaro Alvim, Porto Alegre, Brazil
| | - Claudia M Szobot
- Center for Drug and Alcohol Research (CPAD), Hospital de Clínicas de Porto Alegre (HCPA), Unidade Álvaro Alvim, Porto Alegre, Brazil.,Child and Adolescent Psychiatric Service (SPIA), Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Ricardo Halpern
- Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil
| | - Felix H P Kessler
- Center for Drug and Alcohol Research (CPAD), Hospital de Clínicas de Porto Alegre (HCPA), Unidade Álvaro Alvim, Porto Alegre, Brazil
| | - Flavio Pechansky
- Center for Drug and Alcohol Research (CPAD), Hospital de Clínicas de Porto Alegre (HCPA), Unidade Álvaro Alvim, Porto Alegre, Brazil
| | - Tatiana Roman
- Department of Genetics, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
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Onnink AMH, Franke B, van Hulzen K, Zwiers MP, Mostert JC, Schene AH, Heslenfeld DJ, Oosterlaan J, Hoekstra PJ, Hartman CA, Vasquez AA, Kan CC, Buitelaar J, Hoogman M. Enlarged striatal volume in adults with ADHD carrying the 9-6 haplotype of the dopamine transporter gene DAT1. J Neural Transm (Vienna) 2016; 123:905-15. [PMID: 26935821 PMCID: PMC4969340 DOI: 10.1007/s00702-016-1521-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Accepted: 02/04/2016] [Indexed: 12/20/2022]
Abstract
The dopamine transporter gene, DAT1 (SLC6A3), has been studied extensively as a candidate gene for attention-deficit/hyperactivity disorder (ADHD). Different alleles of variable number of tandem repeats (VNTRs) in this gene have been associated with childhood ADHD (10/10 genotype and haplotype 10-6) and adult ADHD (haplotype 9-6). This suggests a differential association depending on age, and a role of DAT1 in modulating the ADHD phenotype over the lifespan. The DAT1 gene may mediate susceptibility to ADHD through effects on striatal volumes, where it is most highly expressed. In an attempt to clarify its mode of action, we examined the effect of three DAT1 alleles (10/10 genotype, and the haplotypes 10-6 and 9-6) on bilateral striatal volumes (nucleus accumbens, caudate nucleus, and putamen) derived from structural magnetic resonance imaging scans using automated tissue segmentation. Analyses were performed separately in three cohorts with cross-sectional MRI data, a childhood/adolescent sample (NeuroIMAGE, 301 patients with ADHD and 186 healthy participants) and two adult samples (IMpACT, 118 patients with ADHD and 111 healthy participants; BIG, 1718 healthy participants). Regression analyses revealed that in the IMpACT cohort, and not in the other cohorts, carriers of the DAT1 adult ADHD risk haplotype 9-6 had 5.9 % larger striatum volume relative to participants not carrying this haplotype. This effect varied by diagnostic status, with the risk haplotype affecting striatal volumes only in patients with ADHD. An explorative analysis in the cohorts combined (N = 2434) showed a significant gene-by-diagnosis-by-age interaction suggesting that carriership of the 9-6 haplotype predisposes to a slower age-related decay of striatal volume specific to the patient group. This study emphasizes the need of a lifespan approach in genetic studies of ADHD.
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Affiliation(s)
- A Marten H Onnink
- Department of Psychiatry, Radboud University Medical Center, Nijmegen, The Netherlands. .,Department of Human Genetics (855), Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Barbara Franke
- Department of Psychiatry, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Human Genetics (855), Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.,Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, The Netherlands
| | - Kimm van Hulzen
- Department of Human Genetics (855), Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Marcel P Zwiers
- Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, The Netherlands
| | - Jeanette C Mostert
- Department of Human Genetics (855), Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.,Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, The Netherlands
| | - Aart H Schene
- Department of Psychiatry, Radboud University Medical Center, Nijmegen, The Netherlands.,Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, The Netherlands
| | - Dirk J Heslenfeld
- Clinical Neuropsychology Section, Department of Clinical Psychology, VU University Amsterdam, Amsterdam, The Netherlands
| | - Jaap Oosterlaan
- Clinical Neuropsychology Section, Department of Clinical Psychology, VU University Amsterdam, Amsterdam, The Netherlands
| | - Pieter J Hoekstra
- Department of Psychiatry, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Catharina A Hartman
- Department of Psychiatry, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Alejandro Arias Vasquez
- Department of Psychiatry, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Human Genetics (855), Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.,Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, The Netherlands.,Department of Cognitive Neuroscience, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Cornelis C Kan
- Department of Psychiatry, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jan Buitelaar
- Department of Cognitive Neuroscience, Radboud University Medical Center, Nijmegen, The Netherlands.,Karakter Child and Adolescent Psychiatric University Centre, Nijmegen, The Netherlands
| | - Martine Hoogman
- Department of Human Genetics (855), Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
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Tzeng NS, Lu RB, Yeh HW, Yeh YW, Huang CC, Yen CH, Kuo SC, Chen CY, Chang HA, Ho PS, Cheng S, Shih MC, Huang SY. The dopamine transporter gene may not contribute to susceptibility and the specific personality traits of amphetamine dependence. Drug Alcohol Depend 2015; 149:100-7. [PMID: 25683821 DOI: 10.1016/j.drugalcdep.2015.01.030] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2014] [Revised: 01/16/2015] [Accepted: 01/22/2015] [Indexed: 12/01/2022]
Abstract
BACKGROUND A substantial amount of evidence suggests that dysfunction of the dopamine transporter may be involved in the pathophysiology of amphetamine dependence (AD). The aim of this study was to examine whether the dopamine transporter gene (DAT1, SLC6A3) is associated with development of AD and whether this gene influences personality traits in patients with AD. METHODS Eighteen polymorphisms of the DAT1 gene were analyzed in a case-control study that included 909 Han Chinese men (568 patients with AD and 341 control subjects). The patients fulfilled the DSM-IV-TR criteria for AD. The Tridimensional Personality Questionnaire (TPQ) was used to assess personality traits and to examine the association between these traits and DAT1 gene variants. RESULTS A weak association was found between the rs27072 polymorphism and development of AD, but these borderline associations were unconfirmed by logistic regression and haplotype analysis. Although harm avoidance and novelty seeking scores were significantly higher in patients than in controls, DAT1 polymorphisms did not influence these scores. CONCLUSIONS This study suggests that high harm avoidance and novelty seeking personality traits may be a risk factor for the development of AD. However, the DAT1 gene may not contribute to AD susceptibility and specific personality traits observed in AD among Han Chinese men.
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Affiliation(s)
- Nian-Sheng Tzeng
- Department of Psychiatry, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC; Student Counseling Center, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Ru-Band Lu
- Department of Psychiatry, Institute of Behavior Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Hui-Wen Yeh
- Department of Nursing, Kang-Ning Junior College of Medical Care and Management, Taipei, Taiwan; Department of Nursing, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Yi-Wei Yeh
- Department of Psychiatry, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC; Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Chang-Chih Huang
- Department of Psychiatry, Buddhist Tzu Chi General Hospital, Taipei Branch, Taipei, Taiwan, ROC
| | - Che-Hung Yen
- Department of Neurology, Tri-Service General Hospital, Taipei, Taiwan, ROC
| | - Shin-Chang Kuo
- Department of Psychiatry, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC; Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Chun-Yen Chen
- Department of Psychiatry, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC; Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Hsin-An Chang
- Department of Psychiatry, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Pei-Shen Ho
- Department of Psychiatry, Beitou Branch, Tri-Service General Hospital, Taipei, Taiwan, ROC
| | - Serena Cheng
- College of Arts and Sciences, Cornell University, Ithaca, NY, USA
| | - Mei-Chen Shih
- Department of Psychiatry, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC
| | - San-Yuan Huang
- Department of Psychiatry, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC; Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan, ROC.
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